On 9/29/2007, a 61 year old resident choked to death due to the facility's failure to monitor him at mealtime and to provide emergency care to remove food that was obstructing his airway. The resident's care plan called for monitoring during meals because he was at risk of choking due to being toothless. Nonetheless, the facility staff failed to supervise him during dinner on 9/29/07. A nurse found him laying down in his bed and unresponsive at 7 pm. The facility called paramedics, but did not clear his airway or administer CPR in accordance with its policy while waiting for their arrival. Paramedics arrived at 7:19 pm, discovered the resident had food in his airway, and transported him to the hospital, where he was declared dead at 7:45 pm. The cause of death was asphyxiation due to choking. The facility was cited because its failures to implement the resident's care plan, to monitor him during meals, and to provide emergency care in accordance with its policies led to the resident's death.